Patient Profile:
Charlie Brown is a seventeen year old caucasian male. He loves hanging out with family and girlfriend. Charlie loves bowling with his friends. Chief Complaint: Patients mom states that patient's teeth are turning brown and he needs a cleaning. Dental History:
Bleeding gums when brushing: Yes
Clicking or popping: Sometimes popping bilaterally, no pain.
Date of last exam: 02/08
Date of last dental x-rays: 02/08
Date of last teeth cleaning: 02/08
Name of previous dentist: Dr Perio.
Blisters or sores on lips/mouth: Yes when lips are dry.
Burning tongue or lips: When lips are dry.
Recent tooth ache: #7 and #10. Medical History:
Cardiovascular: None
Respiratory: None
Head and Neck:
Visual impairment- glasses since 2009
Social Life: None
Neuromuscular System/ CNS: None
Gastrointestinal/Genito-Urinary: None
Hema/Endo/Immune Disorders:
Tyroid or andrenal gland disease- Hashimotos under control with medication.
Psychological disorders: None
Childhood vaccination: Yes
Hepatitis B vaccination: Yes
Flu vaccination: Yes every year.
Family history:
Diabetes- Paternal grandmother has type 2, is controlled with diet.
Additional information:
Visits speech pathologist to correct tongue position.
Hospitalzations: None
ASA II due to down syndrome and hypothyroidism. Patient Medication:
Clinically Findings: Extra Oral: None Intra Oral: Macroglossia, fissured tongue. bilaterally crepitation, haliotosis, mouth breather.
Intra-oral picture Gingival Description:
Free- Generalized red, bulbous with localized rolled on buccal and lingual of #23-26 and, edematous and glossy.
Attached- Generalized dark, firmly bound to bone, smooth and shiny. MBI 53 % Probing Depths: Generalized 3-4 mm with localized 5 mm on the posterior teeth. BOP: 60 % Recession: facial of 7-1 mm, 10-1 mm, 23-26 1mm, and 28-1 mm. Mucogingival defects: None Mobility: + # 7,9,10, 23-26 Fremititi#6,8,9,11 Furcations: 19 facial class I and 30 facial class II. Angles Class: Class III Facial Profile: Prognanthic Salivary Flow: adequate Radiographic interpretation: Missing teeth: 1,4,16 and 17 (congenitally missing, common sign of down syndrome) Quality of radiograph: Is diagnostic. Trabecular pattern: Is consistent with the exception of the mandibular anterior. Lamina dura: Is intact with the exception of the mandibular anterior.
Area of possible lesion is mixed, irregular, ill defined and spans from apex of 22 to the apex of #29 to the inferior border of the mandible. Differential diagnosis includes: Alveolar crest: Is fuzzy and generally 3mm from the CEJ. PDL: Is widened on the mesial of #2,3, 7, 8, 9, 10, 15, 18, 19, 22, 24,25,31 and distal of # 5, 78,9,10, 14, 15, 19,22,23,24,25,26,30 and 31 Corralation to assesments: The radiographs correlate to the clinical assessements. The widening of the PDL could be due to the clenching and grinding. Restorations: none Areas of concern: The anterior mandibular area. Calculus Code: Medium
ADA type II with localized ADA III.
AAP generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. Referral Form: What about the mixed lesion apically on the LAS? Shouldn't this be reviewed out to a oral surgeon for evaluation? DL
Critical Thinking Form: Treatment Plan: SOAP notes:
Date xx-xx-xx
S: Here for a teeth cleaning.
O: RMH. BP: 117/70, P: 73 R: 20. Pt’s mother states patient took levothyroxine and multi-vitamin this morning.
E and I:
Extra oral: none.
Intra oral: Macroglossia, fissured tongue. bilaterally crepitation, haliotosis, mouth breather. Gingival description: Free- Generalized red, bulbous with localized rolled on buccal and lingual of #23-26 and, edematous and glossy. Attached- Generalized dark pink, firmly bound to bone, smooth and shiny. Max. Opening: 43mm MBI 53 %, BOP: 45% Probing Depths: Generalized 3-4 mm with localized 5 mm on the posterior teeth. Recession: facial of 7-1 mm, 10-1 mm, 23-26 1mm, and 28-1 mm. Mucogingival defects: None Mobility: + # 7,9,10, 23-26 Fremititis: #6,8,9,11 Furcations: 19 facial class I and 30 facial class II. Angles Class: Class III Facial Profile: Prognanthic Salivary Flow: adequate A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium. P: Xray check, gathered assess., DDS, pt’s mother given referral form, second check-in, Plaque index 100%, OHI and Nutritional counseling. NV: OHI, Scale URQ w/ 2% lidocaine anseth., localized chlorohexidine on DL-#3 and Nutrition counseling.---student# Date xx-xx-xx S: Here to have a teeth cleaning. O: RMH. BP: 119/75, P: 67 R: 19. Pt’s mother states patient took levothyroxine and multi-vitamin this morning. A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium. P: OHI, scaled URQ w/ anes. 2% lidocaine w/ epi., admin. Loc. Chlor. DL-#3, nutritional couns. NV: OHI, scale LRQ w/ 2% lidocaine anesth.w/ epi., loc. Chlor. #31 and 28, nutritional couns.---student # Date xx-xx-xx S: Here to have a teeth cleaning. O: RMH. BP: 120/78, P: 70 R: 20. Pt’s mother states patient took levothyroxine and multi-vitamin this morning. A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium. P: OHI, scaled LRQ w/ 2% lidocaine ansesth. w/ epi., loc. Chlor. #31-Ling. M and D, #28-direct buccal., nutrition couns. NV: OHI, scale ULQ w/2% lidocaine anesth. w/epi., nutrition couns.—student # Date xx-xx-xx S: Here to have a teeth cleaning. O: RMH. BP: 120/78, P: 70 R: 20. Pt’s mother states patient took levothyroxine and multi-vitamin this morning. A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium. P: OHI, scaled ULQ w/ 2% lidocaine ansesth. w/ epi., nutrition couns. NV: OHI, scale LLQ w/2% lidocaine anesth. w/epi., loc. Chlor. #19M-B and DB., nutrition couns.—student # Date xx-xx-xx S: Here to have a teeth cleaning. O: RMH. BP: 116/72, P: 75 R: 18. Pt’s mother states patient took levothyroxine and multi-vitamin this morning. A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium. P: OHI, scale LLQ w/2% lidocaine anesth. w/epi., loc. Chlor. #19M-B and DB., nutrition couns. NV: 4-6 mo. Re-eval.—student # Prognosis: With parent and patient cooperation at home and good oral hygiene routines as well as 3 month re-care intervals we feel that the patients prognosis can be improved. Currently the patient has a generalized fair prognosis with a localized poor prognosis. Down's Syndrome: Is a condintion in which extra genetic material causes delays in the way a child develops, both mentally and physically. Down syndrome can not be prevented, it can be detected before the child is born. References: Carranza, F. A., Klokkevold, P. R. Newman, M. G., Takei, H. H. (2006). Carranza's clinical periodontology 10th edition. St. Louis, MO: Saunders Elevier.
Periodontal Case #6 - Down's Syndrome
Patient Profile:
Charlie Brown is a seventeen year old caucasian male. He loves hanging out with family and girlfriend. Charlie loves bowling with his friends.
Chief Complaint: Patients mom states that patient's teeth are turning brown and he needs a cleaning.
Dental History:
Bleeding gums when brushing: Yes
Clicking or popping: Sometimes popping bilaterally, no pain.
Date of last exam: 02/08
Date of last dental x-rays: 02/08
Date of last teeth cleaning: 02/08
Name of previous dentist: Dr Perio.
Blisters or sores on lips/mouth: Yes when lips are dry.
Burning tongue or lips: When lips are dry.
Recent tooth ache: #7 and #10.
Medical History:
Cardiovascular: None
Respiratory: None
Head and Neck:
Visual impairment- glasses since 2009
Social Life: None
Neuromuscular System/ CNS: None
Gastrointestinal/Genito-Urinary: None
Hema/Endo/Immune Disorders:
Tyroid or andrenal gland disease- Hashimotos under control with medication.
Psychological disorders: None
Childhood vaccination: Yes
Hepatitis B vaccination: Yes
Flu vaccination: Yes every year.
Family history:
Diabetes- Paternal grandmother has type 2, is controlled with diet.
Additional information:
Visits speech pathologist to correct tongue position.
Hospitalzations: None
ASA II due to down syndrome and hypothyroidism.
Patient Medication:
Clinically Findings:
Extra Oral: None
Intra Oral: Macroglossia, fissured tongue. bilaterally crepitation, haliotosis, mouth breather.
Intra-oral picture
Gingival Description:
Free- Generalized red, bulbous with localized rolled on buccal and lingual of #23-26 and, edematous and glossy.
Attached- Generalized dark, firmly bound to bone, smooth and shiny.
MBI 53 %
Probing Depths: Generalized 3-4 mm with localized 5 mm on the posterior teeth.
BOP: 60 %
Recession: facial of 7-1 mm, 10-1 mm, 23-26 1mm, and 28-1 mm.
Mucogingival defects: None
Mobility: + # 7,9,10, 23-26
Fremititi#6,8,9,11
Furcations: 19 facial class I and 30 facial class II.
Angles Class: Class III
Facial Profile: Prognanthic
Salivary Flow: adequate
Radiographic interpretation:
Missing teeth: 1,4,16 and 17 (congenitally missing, common sign of down syndrome)
Quality of radiograph: Is diagnostic.
Trabecular pattern: Is consistent with the exception of the mandibular anterior.
Lamina dura: Is intact with the exception of the mandibular anterior.
Area of possible lesion is mixed, irregular, ill defined and spans from apex of 22 to the apex of #29 to the inferior border of the mandible.
Differential diagnosis includes:
Alveolar crest: Is fuzzy and generally 3mm from the CEJ.
PDL: Is widened on the mesial of #2,3, 7, 8, 9, 10, 15, 18, 19, 22, 24,25,31 and distal of # 5, 78,9,10, 14, 15, 19,22,23,24,25,26,30 and 31
Corralation to assesments: The radiographs correlate to the clinical assessements. The widening of the PDL could be due to the clenching and grinding.
Restorations: none
Areas of concern: The anterior mandibular area.
Calculus Code: Medium
ADA type II with localized ADA III.
AAP generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome.
Referral Form:
What about the mixed lesion apically on the LAS? Shouldn't this be reviewed out to a oral surgeon for evaluation? DL
Critical Thinking Form:
Treatment Plan:
SOAP notes:
Date xx-xx-xx
S: Here for a teeth cleaning.
O: RMH. BP: 117/70, P: 73 R: 20. Pt’s mother states patient took levothyroxine and multi-vitamin this morning.
E and I:
Extra oral: none.
Intra oral: Macroglossia, fissured tongue. bilaterally crepitation, haliotosis, mouth breather.
Gingival description: Free- Generalized red, bulbous with localized rolled on buccal and lingual of #23-26 and, edematous and glossy.
Attached- Generalized dark pink, firmly bound to bone, smooth and shiny.
Max. Opening: 43mm
MBI 53 %,
BOP: 45%
Probing Depths: Generalized 3-4 mm with localized 5 mm on the posterior teeth.
Recession: facial of 7-1 mm, 10-1 mm, 23-26 1mm, and 28-1 mm.
Mucogingival defects: None
Mobility: + # 7,9,10, 23-26
Fremititis: #6,8,9,11
Furcations: 19 facial class I and 30 facial class II.
Angles Class: Class III
Facial Profile: Prognanthic
Salivary Flow: adequate
A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium.
P: Xray check, gathered assess., DDS, pt’s mother given referral form, second check-in, Plaque index 100%, OHI and Nutritional counseling.
NV: OHI, Scale URQ w/ 2% lidocaine anseth., localized chlorohexidine on DL-#3 and Nutrition counseling.---student#
Date xx-xx-xx
S: Here to have a teeth cleaning.
O: RMH. BP: 119/75, P: 67 R: 19. Pt’s mother states patient took levothyroxine and multi-vitamin this morning.
A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium.
P: OHI, scaled URQ w/ anes. 2% lidocaine w/ epi., admin. Loc. Chlor. DL-#3, nutritional couns.
NV: OHI, scale LRQ w/ 2% lidocaine anesth.w/ epi., loc. Chlor. #31 and 28, nutritional couns.---student #
Date xx-xx-xx
S: Here to have a teeth cleaning.
O: RMH. BP: 120/78, P: 70 R: 20. Pt’s mother states patient took levothyroxine and multi-vitamin this morning.
A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium.
P: OHI, scaled LRQ w/ 2% lidocaine ansesth. w/ epi., loc. Chlor. #31-Ling. M and D, #28-direct buccal., nutrition couns.
NV: OHI, scale ULQ w/2% lidocaine anesth. w/epi., nutrition couns.—student #
Date xx-xx-xx
S: Here to have a teeth cleaning.
O: RMH. BP: 120/78, P: 70 R: 20. Pt’s mother states patient took levothyroxine and multi-vitamin this morning.
A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium.
P: OHI, scaled ULQ w/ 2% lidocaine ansesth. w/ epi., nutrition couns.
NV: OHI, scale LLQ w/2% lidocaine anesth. w/epi., loc. Chlor. #19M-B and DB., nutrition couns.—student #
Date xx-xx-xx
S: Here to have a teeth cleaning.
O: RMH. BP: 116/72, P: 75 R: 18. Pt’s mother states patient took levothyroxine and multi-vitamin this morning.
A: ASA II, ADA type II with localized ADA III, AAP: generalized slight chronic with localized moderated chronic periodontitis due to plaque and calculus and modified by hypothyroidism and down syndrome. MVC calculus code: medium.
P: OHI, scale LLQ w/2% lidocaine anesth. w/epi., loc. Chlor. #19M-B and DB., nutrition couns.
NV: 4-6 mo. Re-eval.—student #
Prognosis: With parent and patient cooperation at home and good oral hygiene routines as well as 3 month re-care intervals we feel that the patients prognosis can be improved. Currently the patient has a generalized fair prognosis with a localized poor prognosis.
Down's Syndrome: Is a condintion in which extra genetic material causes delays in the way a child develops, both mentally and physically. Down syndrome can not be prevented, it can be detected before the child is born.
References:
Carranza, F. A., Klokkevold, P. R. Newman, M. G., Takei, H. H. (2006). Carranza's clinical periodontology 10th edition. St. Louis, MO: Saunders Elevier.